The Effects of Case Management and Community Services on
the Impaired Elderly

Executive Summary

Randall Brown and Barbara Phillips

Mathematica Policy Research, Inc.

February 1986

This report was prepared under contract #HHS-100-80-0157 between
the U.S. Department of Health and Human Services (HHS), Office of Social
Services Policy (now the Office of Disability, Aging and Long-Term Care Policy)
and Mathematica Policy Research, Inc. For additional information about the
study, you may visit the DALTCP home page at
http://aspe.hhs.gov/daltcp/home.htm or contact the office at HHS/ASPE/DALTCP,
Room 424E, H.H. Humphrey Building, 200 Independence Avenue, SW, Washington, DC
20201. The e-mail address is: webmaster.DALTCP@hhs.gov. The DALTCP Project
Officer was Robert Clark.

The National Long Term Care Demonstration was developed in response to
rapidly increasing private and public expenditures for care of the elderly. The
Channeling demonstration, as it is referred to, sought to decrease costs of
care for the elderly and improve their well-being by substituting in-home
community-based care for institutional care. The program's essential feature
was comprehensive case management, a system for coordinating the many formal
community-based services that were already available to elderly individuals.
The existing service system was comprised of many different providers, most of
which provided a limited range of services to address specific client needs;
Channeling sought to improve on this by identifying and addressing the full
range of clients' needs. The program also had access to funds to purchase
additional services for clients.

The evaluation of the demonstration has been conducted and presented in
various reports, each dealing with different types of expected effects. Many
different outcomes were examined, with the general finding that Channeling
increased the service receipt and well-being of clients but did not
substantially reduce the use of nursing homes and had no effect on hospital
use. This result led to questions about why the program was only partially
successful and has raised somewhat broader questions about the availability and
effects of case management and community services in general.

The Channeling evaluation featured a randomized design. Eligible
applicants to the program in each of the ten demonstration sites were randomly
assigned to the treatment group, which was offered the opportunity to
participate in the Channeling program, or to the control group, which was
barred from participation. Both groups received baseline assessment interviews
to gather data on their initial characteristics and followup interviews 6, 12,
and (for half of the sample) 18 months later to obtain data on outcomes that
Channeling could be expected to affect. The randomized design ensures that
comparison of these two groups provides reliable estimates of Channeling
impacts, defined as the difference between treatment group members' actual
outcomes and that which they would have experienced in the absence of the
program.

This definition, while technically correct, could result in relatively
small estimates of program impacts even if Channeling actually were very
effective in alleviating clients' needs and substituting formal in-home care
for institutional care. This could occur if only a fraction of the treatment
group actually participated in Channeling or if a substantial proportion of the
control group received case management or community services from existing
agencies that closely resembled those provided or arranged for by Channeling.
The fact that treatment/control differences indicate no impacts of Channeling
on hospital or nursing home use may merely reflect the already rich service
environments into which the demonstrations were introduced. On the other hand,
such services may have little impact on institutional use in any case.

To distinguish between these two alternative explanations we first
examined the type and amount of case management and services received by the
control group, and compared that to what was received by treatment group
members. We then estimated equations that were intended to address the
following specific questions:

What are the impacts of case management and formal in-home services
on outcomes of interest?

Do these impacts differ for Channeling and nonChanneling
clients?

Do impacts vary with the comprehensiveness of case
management?

Knowledge of the differences between treatments and controls in the
quantity and nature of services received, combined with reliable estimates of
the difference in effectiveness between Channeling and other providers of case
management and services would enable us to disentangle the possible reasons for
the lack of significant treatment/control differences on key outcomes.

Pursuing this strategy, we first described the different features of
comprehensive case management, as offered by Channeling, then examined the
extent to which other agencies in the demonstration sites offered a comparable
level of case management. We found that in most of the demonstration sites,
case management that was at least close to being as comprehensive as that
provided by Channeling was already available, but that only 10-20 percent of
controls received it, depending on the model and time period. That proportion
increased to as much as 35 percent when case management that was ongoing (i.e.,
that incorporated monitoring and reassessment of service adequacy over time)
but perhaps less comprehensive than Channeling was included. Finally, taking
into account the case management provided by home health agencies, the
proportion of controls who may be presumed to have received some case
management rose to 60 percent in the basic model and 75 percent in the
financial model. Thus, although not many controls received case management that
was comparable to that offered by Channeling, the proportion receiving at least
some case management was very high.

Comparable data for the treatment group showed that the proportion
reporting receipt of ongoing case management was 30-50 percentage points higher
than the control group rate, depending on the time period, model, and measure.
When home health services are included in the case management measure the
proportion of the treatment group receiving services exceeds the control group
rate by 20-30 percentage points. These differences, while no trivial, are
substantially less than 100 percent, which suggests that Channeling is more
properly thought of as a test of the effectiveness of alternative types of case
management, rather than a test of case management per se.

Taking an analogous approach to formal community based services, we
found that 14-19 percent of the control group received skilled services
(nursing or therapy) and 50-64 percent received semi-skilled services
(homemaking, personal care, housekeeping, etc.) during the reference week.
Receipt of skilled services differed little between treatment and control
groups, but semi-skilled services were received by a significantly higher
proportion of treatments than controls in both models. Service recipients in
the treatment group tended to receive more hours of care than control group
recipients as well, at least in the financial model. Nonetheless, half of the
controls in the basic model and nearly two-thirds in the financial model were
receiving some semi-skilled services. Thus, it is clear that Channeling was not
being compared to a situation in which no other services were available but to
a situation in which a significant quantity and quality of case management and
services were already being provided.

The next step was to estimate the impacts of case management and
services on outcomes of interest, for both treatment groups in both models.
Using regression to control for other differences between recipients and
nonrecipients of case management and services that could affect outcomes, we
found that neither skilled services nor any of several measures of case
management seemed to have much effect on nursing home admissions or days.
However, receipt of semi-skilled services was associated with significantly
lower use of nursing homes. Although these results were plausible, we were
concerned that the estimated impacts for case management and services reflected
the effects of unobserved differences between recipients and nonrecipients of
services (not controlled for by the baseline explanatory variables in the
model), rather than the true effects of these services on nursing home use.
This concern was heightened when we substituted six month measures of case
management and services for the concurrent 12 month measures in estimating
impacts on institutional use during the 7-12 month period, and obtained
estimated impacts of semi-skilled services that were of the opposite sign as
obtained with concurrent measures and no longer statistically significant. We
also found that higher unmet needs and more informal care were associated with
receipt of semi-skilled services, which further supported the belief that the
regression model failed to control fully for the differences between recipients
and nonrecipients of services.

An econometric procedure, two stage least squares, was then used to
eliminate the effects of these unobserved factors on our estimates. This
procedure is designed to eliminate the bias caused by the unobserved factors
reflected in the case management and service variables by replacing these
variables in the regression with predicted values of these services. However,
because it was difficult to predict with much accuracy which sample members
actually received case management and services, the procedure produced
estimated impacts that were anomalous in size, of the wrong sign in some cases,
and nearly always insignificant because of very large standard errors. Thus, we
were unable to rely on statistical procedures to resolve the ambiguity about
the original regression estimates.

As a final way to resolve the discrepancy between the estimated impacts
using lagged instead of concurrent values of semi-skilled services we examined
the data further and found that the difference was due to a fairly large
proportion of those admitted to a nursing home in months 7-12 reporting receipt
of services during the 6 month reference week but not for the week prior to
entering the institution. Although there were few cases involved (because of
the low nursing home admission rate) the potential implications for our results
were considerable: if some sample members living in the community are forced
into nursing homes when they suddenly lose the formal services they are
receiving, this would be an important finding. Medicare records of the
individual sample members in question were inspected and found to support the
interview data, thus ruling out sample member recall problems as an alternative
explanation. However, the average number of hours of care received was quite
small for most of these cases, making it unlikely that loss of this level of
care was responsible for their admittance to a nursing home. It seemed rather
more likely that other events were responsible for the sample member being
admitted, and once this occurred formal community care was terminated.

Because of the ambiguity of the results we are unable to determine from
these data whether case management and formal community services affect nursing
home use or other outcomes. While it is tempting to conclude from the initial
results that receipt of semi-skilled services reduces institutional use. The
drastic change in results when lagged values of semi-skilled services were
substituted for concurrent measures, the failure of the model to show that
unmet needs decline in response to services, and the erratic two-stage least
squares estimates all cast doubt on the interpretation of the regression
estimates as evidence that semi-skilled services reduce nursing home use. It is
clear from the results that case management and services were widely available
to and received by controls in the Channeling sites. Whether the general lack
of significant treatment/control differences observed in the Channeling
evaluation is due to the widespread receipt by controls of services that are
comparable in effectiveness to those delivered by Channeling or due to a lack
of impacts of any case management or services on institutional use is
unclear.

While this result is disappointing it is not surprising. It was clear
from the outset of this analysis that differences in mean outcomes between
recipients and nonrecipients of case management and formal care could not be
attributed to the effects of those services unless the other factors that
distinguish these two groups could be controlled for. It was also recognized
that this would be difficult to do because of the many unobserved factors that
influence both receipt of services and key outcomes such as institutional use.
The procedures that were employed were intended to overcome these problems, but
the inherent complexity of the institutionalization process and the lack of a
data set collected expressly for the purpose of measuring the impacts of case
management and services were difficulties too severe to be overcome by
econometric models.

What we have learned from analysis of the Channeling data is that the
comprehensive form of case management offered by Channeling is effective in
reducing unmet needs and increasing client and caregiver satisfaction with
life. This impact is an especially impressive achievement given the extensive
services received by the control group. However, we also know that
Channeling-like programs are not more effective than less comprehensive case
management in reducing institutional use; only a small fraction of the control
group received such intensive case management and yet no significant
treatment/control differences in nursing home use were obtained. What we have
not been able to determine is whether a less comprehensive form of case
management or even services without case management are sufficient to reduce
institutional use. Reliable answers to these questions will require data that
is more directly focused on this question.